What are the responsibilities and job description for the Claims Adjuster FT position at Kaiser Permanente?
Job Summary:
Reviews claims and makes payment and benefit determination. Conducts research as it relates to claims processing for medical appropriateness, and diagnosis, using ICD-9 codes and CPT codes as required.
Essential Responsibilities:
- Reviews claims and makes payment determination with authorization limit to $9,999 per claim.
- Conducts research regarding medical appropriateness, coordination of benefits issues, fraud and abuse, and third party liability.
- Checks with Lead and Supervisor for any claim exceeding $9,999.
- Provides input to Supervisor regarding trends related to training, education to enhance department production and processes.
- Utilizes knowledge of government regulatory policies and procedures to ensure compliance with government regulations including but limited to CMS, DMHC, DHS and requirements of accrediting agencies such as NCQA.
- Proactively works to ensure claims are review & processed timely.
Qualifications:
Basic Qualifications:
Experience
- Three (3) to five (5) years Medical claims processing experience in a HMO/Indemnity environment including technical research and analysis experience.
- Claims System OCPS; Windows NT; Word, Excel, Lotus Notes. Excellent skills in communication Medical Claims Processing.
- CPT, ICD-9, Medical Terminology, COB/TPL/WC
- Demonstrate ability to utilize Medical Terminology and International Classification
- Diagnosis (ICD-9), HCPCS&CPT coding at a level appropriate to the job.
Education
- High School Diploma/GED
License, Certification, Registration
- N/A
Additional Requirements:
Preferred Qualifications:
- Medical Terminology Certificate Preferred
Salary : $39 - $43